Comparative Analysis of the Serbian and German Legislation on Emergency Medical Services
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Wolfgang Tiede and Christine Simon Comparative analysis of the Serbian and German legislation on emergency medical services Abstract The political developments in Serbia and the hostilities and economic sanctions of the nineties resulted in a significant deterioration of the economy. These circum- stances gave rise to damage to and neglect of the infrastructure, as well as of the administrative structure of the country. Hence, it is not surprising that the present population health standard of Serbia is, although similar to other central and eastern European countries, still below that of western Europe. In view of this background, the article will firstly describe the present Serbian legislation on emergency medical services. Subsequently, it comments on the German legislation on emergency me- dical services as an exemplar of the respective regulation of a western European state. Based on these descriptions and with reference to EU legal standards, a comparison between the two legislations is drawn. The article concludes with re- commendations for possible improvements to the Serbian legislation on emergency medical services. Keywords: EU accession, emergency medical services, legislation, health insuran- ce systems, quality criteria in health care, continuing training, professional specia- lisation, competences of EU, standardisation in EU Introduction Serbia is currently in a phase of pre-accession to the EU. This indeed necessitates, but then also accelerates, an approximation towards western European standards. At pre- sent, Serbia is rebuilding its economy and infrastructure. Furthermore, it is implemen- ting an extensive programme of decentralisation. The measures emerging alongside this process of rapid transition have an influence on all sectors of government and civil society. In particular, legislation is being adapted to meet new national priorities, in- cluding harmonisation with EU norms and standards. With regard to the health sector, the Serbian government has made its reform a national priority. The ministry of health prepared a Strategy and action plan for health care reform in early 2003. The reform of primary health care in particular was cited as a high priority reform by the Decree on the network plan for health institutions (2006). This might inter alia have been caused by the results of several reviews and assessments which were carried out to support health care reform. The outcomes of these mainly indicated the need for im- provements in the range of emergency medical services as a part of primary health care. Some areas, such as knowledge, skills, team work capacities and emergency procedu- res, were assessed as lower than the standards of the EU. It was further suggested that the approach to emergency care should be more systematic. 2/2009 South-East Europe Review S. 263 – 293 263 Wolfgang Tiede and Christine Simon Serbian legislation on emergency medical services The Serbian legislation regulating the emergency medical services (EMS) is found in legal provisions at different levels and is, therefore, quite fragmented. The Health Care Law as well as the Health Insurance Law form the legal basis and these define the functioning and organisation of EMS in Serbia. Moreover, there are several subordinated regulations, such as the Network plan for health institutions, the Rule book on the conditions and the means of internal organi- sation of health institutions or the Rule book on detailed conditions for the performance of health activities in the health institutions and other forms of health services. These regulate the structure of health care units as well as the medical personnel required for the performance of emergency medical care (EMC). The Rule book on the content and scope of rights to health care lists, among other issues, the health care services which should be provided in emergency medical cases as well as their scope. In addition, the Rule book on the quality criteria and methodology explanation for the procedures of reporting by health institutions on the mandatory quality criteria of health care pre- scribes, amongst others, the quality criteria which should be followed when performing EMC at primary, secondary and tertiary levels of health care. The Rule book on the practical training and the expert examination of health workers and medical associa- tes and the Rule book on specialisation and advanced specialisation of health workers and medical associates regulates the education and training of health care workers in different areas of health care, including EMC. There is also a codex of professional ethics defining the rights of patients and the duties of physicians. The number of regulations regarding EMS emphasises the great importance which is basically attached to this issue. In order to prove whether the respective provisions meet the demands one should made of an efficient EMS, the particular regulations are examined more closely in the next few sections. Health care law As mentioned before, the Health Care Law (HCL) is the legal foundation of EMS in Serbia. It regulates the different ways of performing EMS and how this is organised. These issues are not laid down in one place but can be found in the following provisions of the HCL. Obligation to provide emergency medical care In its introductory provisions within the chapter ‘Social care for the health of the po- pulation’, the HCL obliges not just EMS units to provide EMC, but also the whole society. By this, it means the Republic of Serbia, by providing financial coverage from the health insurance or budgetary resources (Art. 11, HCL; Article 22, Health Insurance Law (hereinafter HIL); and Article 23 of the Rule book on the content and scope of rights to health care covered by health insurance financial resources and on co-pay- ment for 2009); employers, by providing first aid in the case of industrial injury and by providing conditions for EMC (Art. 14, prov. 1, bullet 12, HCL); and individuals, by providing first aid, as well as accessibility to the EMS unit to injured or ill people in urgent cases and within the limits of their own knowledge and possibilities. 264 South-East Europe Review 2/2009 Comparative analysis of the Serbian and German legislation on emergency medical services Special relevance of emergency medical services assigned by the health care law The HCL regulates the right of the patient to self-determination and consent but, in some cases, it allows that EMS can be performed even without the patient’s consent. This applies if the patient is unconscious or cannot give consent for other reasons (Art. 34, HCL). Within the process of medical treatment, patients have not only rights but duties as well. They have to participate actively in the protection, preservation and improvement of their health, and appraise competent health workers of full information of their state of health, as well as follow the instructions and undertake the measures of therapy prescribed by the health worker in charge. Should the patient fail to adhere to these obligations, the physician may refuse any further provision of health care to the patient except for emergency medical care (Art. 43, HCL). During standby hours, a doctor on call must, even though s/he does not have to be present in the health care facility, be constantly available for the purpose of providing emergency medical care (Art. 78, prov. 3 HCL). According to Article 171 of the HCL, a health worker can reject the provision of health care if this is not in accordance with his or her conscience or within the inter- national rules of medical ethics. This rejection is called conscientious objection. Howe- ver, s/he may not refuse to provide emergency medical care by expressing conscientious objections. Organisation of emergency medical services As regards the organisation of EMS units, Art. 47, prov. 3 of the HCL refers to the Network plan for health institutions (the Network Plan). The HCL still provides the general framework for the organisation of EMS. Pursuant to Art. 56 of the HCL, health care providers in Serbia are generally divided into health institutions and private prac- tices, but only health institutions are allowed, under certain conditions, to perform EMS as a health activity. a) Health institutions A health institution is a health care facility that is engaged in healthcare activity at the primary level and provides health care to certain groups of the population or, otherwise, healthcare activity in certain areas of health care (Art. 102 HCL). i) Institute for Emergency Medical Care Art. 105 of the HCL defines the Institute for Emergency Medical Care (IEMC) as the health institution at the primary level of health care which performs EMC as well as carrying out the medical transport of acutely ill and injured people to other appropriate health institutions, the transport of patients on dialysis and the provision of medicines administered in emergency cases. ii) Primary health care centre The Primary Health Care Centre (PHCC) is a health institution which performs health activities at the primary level of health care (Art. 94 HCL). Art. 95 of the HCL defines the PHCC, or Dom Zdravlja, as the health institution providing, inter alia, EMC. It also 2/2009 South-East Europe Review 265 Wolfgang Tiede and Christine Simon provides ambulance transport if that service is not organised from within a hospital or another health care facility in the territory for which the PHCC has been founded (Art. 95 prov. 3 HCL). iii) Local clinic A PHCC may not be accessible to the whole Serbian population, so there are possibi- lities to establish healthcare outpatient units and local clinics in accordance with the Network Plan. A local clinic is a unit of the PHCC which performs at least EMC, general medicine and paediatrics (Art. 97 HCL). b) Private practice According to Art. 56, prov. 6 of the HCL, a private practice is not allowed to perform or engage in EMS activity.